Abstract
Purpose
The spot sign is associated with intracerebral hemorrhage (ICH) expansion and neurological decline. However, the relationship of the spot sign to secondary intraventricular hemorrhage (IVH) has not been well established. The presence of the spot sign in secondary IVH may provide information regarding neurologic outcome in a population with known poor prognosis.
Methods
A subset analysis was performed of patients with IVH from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-II) study, a randomized clinical trial examining the effect of intensive blood pressure reduction on hematoma expansion. The presence of the spot sign was determined on CTA and IVH expansion was measured in the first 24 hours. The primary outcome measure was early neurological decline (END), defined as ≥ 2-point decrease in Glasgow Coma Scale (GCS) score or ≥ 4-point increase in NIH Stroke Scale (NIHSS). Secondary outcomes including various radiological and clinical factors were also measured.
Results
Of 57 patients included in this analysis, the spot sign was present in 17 (29.8%). The spot sign was a predictor of END in univariate (P < 0.005 for GCS and P = 0.04 for NIHSS) and multivariate analyses using GCS scores (OR=7.2, CI 1.6 – 32.5, P = 0.01). Median 90 day modified Rankin Scale (mRS) scores were significantly different between spot sign-positive and spot sign-negative groups (P = 0.02).
Conclusions
The presence of the spot sign is associated with END in patients with secondary IVH. Identifying this radiologic feature could have important implications for triaging these patients to the appropriate level of care.
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Acknowledgements
We would like to thank to Dr. Hang Lee from the Massachusetts General Hospital Harvard Catalyst Biostatistics Program for his assistance in data analysis.
Funding
The present study was supported by award 5R01NS073344 from the National Institute of Neurological and Communicative Disorders and Stroke. The funding source did not have any involvement in study design; data collection, analysis, and interpretation, writing of the manuscript or decision to submit the study for publication.
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Javier M. Romero, MD contributed to the study conception and design. Material preparation, data collection and analysis were performed by Javier M. Romero MD, Jennifer Soun MD, and Daniel Montes MD. The first draft of the manuscript was written by Jennifer Soun MD, and Daniel Montes MD. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
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J.N. Goldstein: Consulting from CSL Behring and Octapharma, research support from Pfizer and Portola. J.E. Soun, D. Montes, F. Yu, A. Morotti, A.I. Qureshi, I. Barnaure, J. Rosand, and J.M. Romero declare that they have no competing interests.
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The authors Jennifer E. Soun and Daniel Montes contributed equally to the manuscript.
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For a complete list of the ATACH-II and NETT investigators, please refer to: Morotti A, Brouwers HB, Romero JM, Jessel MJ, Vashkevich A, Schwab K, et al. Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage: A Secondary Analysis of a Randomized Clinical Trial. JAMA Neurol. 2017;74:950–960.
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Soun, J.E., Montes, D., Yu, F. et al. Spot Sign in Secondary Intraventricular Hemorrhage Predicts Early Neurological Decline. Clin Neuroradiol 30, 761–768 (2020). https://doi.org/10.1007/s00062-019-00857-2
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DOI: https://doi.org/10.1007/s00062-019-00857-2